Doctor, why is your hospital better than any other?

I took a deep breath. I had to think carefully. It’s not that this was unexpected – Johns Hopkins has been anointed the country’s best hospital for 21 years running by US News. But I wanted to tell the patient the truth without alienating them or failing to mention the many admirable aspects of my institution.

One truth, however, cannot be denied: to call one hospital the best is not simple.

Let’s start with the US News recommendations. The magazine does not reveal its methodology, but a paper in the Annals of Internal Medicine, showed that the ratings correlate quite closely to the institutions’ reputation, and have little to do with objective criteria.

There are methods to rank hospitals besides reputation, but they are still limited. Most publicized has been the dispute over the money that hospitals spend on patients near the end of their life. Researchers at Dartmouth have done a lot of work to control these expenditures for other differences of population and comorbidity. Leaving aside the striking geographic variation in end-of-life costs, the question then is whether the hospitals that spend more are doing so for a good reason. Dartmouth, in general,believes not – but there are other researchers who make the case (usually in more limited geographical regions) that more spending sometimes leads to better care on the part of hospitals.

Then, there are methods to compare hospitals according to various measures necessary to good medical practice (“process measures”). Using the Hospital Compare website, you can compare hospitals on the completeness of their medical therapy for heart failure, or the time it takes a patient – in that hospital – to receive antibiotics for pneumonia in their emergency room (not to mention their rates of infection).

Of course, such measures – like any comparisons – can lead to unintended consequences. Some argue that pneumonia is more likely to be misdiagnosed if it forms part of a core measure, since there is no incentive to avoid giving unneeded antibiotics. This is a larger problem – no comparisons are made for lack of waste – but we won”t go into that here. In general, it is unclear whether public reporting of such data improves effectiveness or safety of healthcare.

A bigger problem, perhaps, for the patient-centeredness that  medicine should aspire to, is the lack of reliable, valid hospital comparison measures that are patient-determined. There is a patient survey which attempts to address patient-centered measures. It’s called the HCAHPS, and includes questions about doctor-patient communication and whether the patient feels like he or she was listened to in the hospital. (Interestingly, comparing Hopkins to other area hospitals shows no great difference on these measures.) However, the response rate is around 20 to 30% for most questions (it’s a mail-in survey), and there are no questions about important aspects of the patient experience, including whether the patient’s emotions and opinions about the plan of care were taken into account by their providers.

These measures, albeit imperfect, are based on data, unlike the US News rankings. Nevertheless, many patients do look to reputation to help them choose a hospital. Hospitals (like my own) use such rankings for publicity, which in turn influences public opinion about what makes a good hospital.

What does that mean for my workplace? Johns Hopkins is considered by US News to be the best hospital based on its reputation – which is not undeserved. I have wonderful colleagues. But like many other medical centers, we have a lot of work to do to accomplish the much-vaunted triple aim of better health, better-quality healthcare, and lower cost. Like everyone else, the patients we see are not healthy; our healthcare is not patient-centered; and we waste a lot of money. Luckily enough, we are starting to fix these issues in a real way. I hope soon to be involved in making care at Hopkins patient-centered no matter what department or clinic the patient happens to be in. This is a great time to make sure that Hopkins’ ranking justifies its reputation, and show that patients feel that way too, whenever we start to disseminate rankings that patients help determine.

Zackary Berger is a faculty member of the Johns Hopkins University School of Medicine, where he is an internist and researcher in general internal medicine.

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